Validation of the Denver Emergency Department Trauma Organ Failure Score to Predict Post-Injury Multiple Organ Failure.

BACKGROUND: Early recognition of trauma patients at risk for multiple organ failure (MOF) is important to reduce the morbidity and mortality associated with MOF. The objective of the study was to externally validate the Denver Emergency Department (ED) Trauma Organ Failure (TOF) Score, a 6-item instrument that includes age, intubation, hematocrit, systolic blood pressure, blood urea nitrogen, and white blood cell count, which was designed to predict the development of MOF within 7 days of hospitalization. STUDY DESIGN: We performed a prospective multicenter study of adult trauma patients between November, 2011 and March, 2013. The primary outcome was development of MOF within 7 days of hospitalization, assessed using the Sequential Organ Failure Assessment Score. Hierarchical logistic regression analysis was performed to determine associations between the Denver ED TOF Score and MOF. Discrimination was assessed and quantified using a receiver operating characteristics (ROC) curve. The predictive accuracy of the Denver ED TOF score was compared with attending emergency physician estimation of the likelihood of MOF. RESULTS: We included 2,072 patients with a median age of 46 years (interquartile range [IQR] 30 to 61 years); 68% were male. The median Injury Severity Score was 9 (IQR 5 to 17), and 88% of patients had blunt mechanism injury. Among participants, 1,024 patients (49%) were admitted to the ICU, and 77 (4%) died. Multiple organ failure occurred in 120 (6%; 95% CI 5% to 7%) patients and of these, 37 (31%; 95% CI 23% to 40%) died. The area under the ROC curve for the Denver ED TOF Score prediction of MOF was 0.89 (95% CI 0.86 to 0.91) and for physician estimation of the likelihood of MOF was 0.78 (95% CI 0.73 to 0.83). CONCLUSIONS: The Denver ED TOF Score predicts development of MOF within 7 days of hospitalization. Its predictive accuracy outperformed attending emergency physician estimation of the risk of MOF.

Envenomation by the Great Lakes Bush Viper (Atheris nitschei).

INTRODUCTION: We present a case of envenomation by a Great Lakes Bush Viper, Atheris nitschei. Atheris species are a group of snakes that are indigenous to the forested areas of Central Africa. Prior reports of envenomation by Great Lakes Bush Vipers were not found in a Medline search. However, reports of other Atheris species envenomations describe coagulopathy and acute renal failure. CASE DETAILS: A 30-year-old male was bitten by a Great Lakes Bush Viper on his left hand. His left upper extremity was edematous with ecchymoses in the left axilla. There was bleeding from the bite site and from the patient's oral mucosa. Initial laboratory studies demonstrated significant derangement of hematologic parameters including anemia, thrombocytopenia, coagulopathy, and hypofibrinoginemia. There is no antivenom for this species. The patient was treated with blood products. Mucosal bleeding ceased within 12 h of admission. DISCUSSION: Atheris nitschei is an African snake with no available antivenom. In this case, the patient developed coagulopathy with hemolytic anemia, thrombocytopenia, and low fibrinogen. Renal function remained unaffected. Despite the lack of specific antivenom or the use of plasmapheresis, our patient was successfully treated with transfusion of multiple blood products.